Inspection Reports for Harrison Terrace
1924 WELLESLEY BLVD, INDIANAPOLIS, IN, 46219
Back to Facility ProfileInspection Report Summary
The most recent inspection on January 28, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a mix of compliance and deficiencies, with issues primarily related to Life Safety Code requirements and resident care, including supervision of residents with dementia and kitchen sanitation. Complaint investigations were mostly unsubstantiated, except for substantiated cases involving resident supervision and abuse incidents in 2022 and 2023, including an immediate jeopardy situation that was resolved with corrective actions. No fines, license suspensions, or enforcement actions were listed in the available reports. The facility’s inspection history shows some improvement in Life Safety compliance over time, though resident care and safety supervision issues appeared intermittently.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
67% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
100% occupied
Based on a January 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 77
Capacity: 77
Deficiencies: 0
Jan 28, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00451660.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00451660 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 77
Census Payor Type Medicaid: 63
Census Payor Type Other: 14
Inspection Report
Re-Inspection
Census: 72
Capacity: 110
Deficiencies: 0
Nov 7, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 09/12/24 by the Indiana Department of Health.
Findings
Harrison Terrace was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 NFPA 101 Life Safety Code. The facility is fully sprinklered with appropriate fire alarm and smoke detection systems.
Report Facts
Facility capacity: 110
Census: 72
Inspection Report
Life Safety
Census: 73
Capacity: 110
Deficiencies: 7
Sep 12, 2024
Visit Reason
The survey was conducted as a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101 standards.
Findings
The facility was found not in compliance with several Life Safety Code requirements including illegible fire resistance rating labels on cross corridor doors, failure of doors to self-close and latch, inadequate separation of hazardous areas, impediments to corridor door closing, incomplete electrical receptacle testing documentation, unsecured emergency power supply overcurrent devices, incomplete emergency generator load testing, and use of non-fused multiplug adapters as substitutes for fixed wiring.
Severity Breakdown
SS=E: 5
SS=C: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Fire resistance rating labels on 1 of 7 cross corridor door sets were illegible and 1 door failed to self-close and latch. | SS=E |
| 1 of over 18 hazardous areas such as trash collection rooms was not separated by smoke resistant partitions and doors that self-close and latch. | SS=E |
| 1 of over 50 corridor doors to resident sleeping rooms had impediment to closing and latching and would not resist passage of smoke. | SS=E |
| Documentation of electrical outlet receptacle testing for select resident sleeping rooms was incomplete and not available for all rooms within the most recent 12 months. | SS=E |
| Overcurrent protective devices in Emergency Power Supply Systems circuits were accessible to unauthorized persons (emergency generator transfer switch in unlocked cabinet). | SS=C |
| 36-month emergency generator load testing was not performed in accordance with NFPA 110 requirements; load testing did not achieve required minimum load. | SS=C |
| Non-fused multiplug adapters were used as substitutes for fixed wiring in the Director of Nursing's office. | SS=E |
Report Facts
Certified beds: 110
Census: 73
Cross corridor door sets inspected: 7
Hazardous areas inspected: 18
Corridor doors inspected: 50
Electrical receptacle testing documentation date: Apr 13, 2024
Emergency generator load test dates with insufficient load: 5
Emergency generator rating: 300
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Taylor Shuey | Executive Director | Named in exit conference and plan of correction |
Inspection Report
Annual Inspection
Census: 70
Capacity: 70
Deficiencies: 7
Aug 29, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00436961.
Findings
The facility was cited for multiple deficiencies including failure to notify medical providers of abnormal blood sugar levels, incomplete orthostatic blood pressure monitoring, inadequate bowel management, failure to provide therapeutic diets as ordered, unsanitary kitchen conditions including dirty floors, vents, and ice machines, improper trash containment, and presence of flying insects in the kitchen.
Complaint Details
Complaint IN00436961 was investigated during this visit with Federal/State deficiencies cited related to the allegations.
Severity Breakdown
SS=D: 4
SS=F: 3
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to notify medical provider for blood sugars exceeding parameters for Resident 45. | SS=D |
| Failed to ensure orthostatic blood pressures were completed and documented as ordered for Resident 17. | SS=D |
| Failed to provide effective services for monitoring and relieving constipation for Resident B. | SS=D |
| Failed to ensure a resident receiving dialysis was provided the therapeutic diet as ordered (Resident 31). | SS=D |
| Failed to maintain clean flooring, ceiling vents, and ice machine in the kitchen. | SS=F |
| Failed to ensure trash was contained in receptacles properly around dumpsters. | SS=F |
| Failed to ensure kitchen was free of flying insects. | SS=F |
Report Facts
Survey dates: 5
Census: 70
Total capacity: 70
Residents on Medicaid: 56
Residents on other payor types: 14
Blood sugar readings above 300: 4
Orthostatic blood pressure readings missing: 2
Days without bowel movement: 5
Ice machine cleaning frequency: 3
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 29, 2024
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on August 29, 2024, which included paper compliance to the Investigation of Complaint IN00436961 completed on August 29, 2024.
Findings
Harrison Terrace was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding paper compliance to the Recertification, State Licensure Survey, and Complaint Investigation.
Inspection Report
Complaint Investigation
Census: 73
Capacity: 73
Deficiencies: 0
Mar 1, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00429062.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00429062 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 73
Total Capacity: 73
Medicaid Census: 52
Other Payor Census: 21
Inspection Report
Complaint Investigation
Census: 73
Capacity: 73
Deficiencies: 0
Jan 22, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00420605, IN00422866, and IN00425520.
Findings
No deficiencies related to the allegations in complaints IN00420605, IN00422866, and IN00425520 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaints IN00420605, IN00422866, and IN00425520 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 73
Census Payor Type Medicaid: 53
Census Payor Type Other: 20
Inspection Report
Re-Inspection
Census: 71
Capacity: 110
Deficiencies: 0
Sep 7, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 07/17/23 was performed to verify compliance with fire safety and licensure requirements.
Findings
At this PSR Code survey, Harrison Terrace was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code.
Report Facts
Facility capacity: 110
Census: 71
Inspection Report
Complaint Investigation
Census: 71
Capacity: 71
Deficiencies: 0
Sep 6, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00416768.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaint IN00416768 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 71
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 55
Census Payor Type - Other: 15
Inspection Report
Annual Inspection
Census: 69
Capacity: 110
Deficiencies: 9
Jul 17, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with federal regulations.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but had multiple deficiencies related to Life Safety Code including fire door self-closing failures, missing exit signage, outdated smoke alarms, hazardous area door issues, fire alarm system labeling, sprinkler system maintenance, smoke barrier penetrations, and non-hospital grade electrical receptacles.
Severity Breakdown
SS=E: 7
SS=D: 1
SS=F: 2
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 7 cross-corridor door sets would self close and latch into the door frame. | SS=E |
| Failed to ensure 1 of 12 doors to the outside were not mistaken as a facility exit due to missing NO EXIT signage. | SS=E |
| Failed to replace battery operated smoke alarms installed in 6 of 55 resident sleeping rooms that were over 10 years old. | SS=E |
| Failed to ensure 1 of over 15 hazardous areas (kitchen trash room) was separated by smoke resistant partitions and doors; door failed to self close and latch. | SS=D |
| Failed to maintain fire alarm system circuit disconnecting means properly identified and secured. | SS=F |
| Failed to maintain ceiling construction for 1 of 1 ceiling sprinklers; missing escutcheons and protective cap still affixed to sprinkler. | SS=E |
| Failed to maintain automatic sprinkler systems; deficiencies noted including missing escutcheons, damaged deflectors, corrosion, and improper sprinkler locations. | SS=F |
| Failed to ensure 1 of 7 smoke barrier walls was protected to maintain the fire resistance rating; annular space around sprinkler pipe not firestopped. | SS=E |
| Failed to ensure nonhospital-grade electrical receptacles that failed testing in 2 of 55 resident rooms were replaced with hospital-grade receptacles. | SS=E |
Report Facts
Certified beds: 110
Census: 69
Cross-corridor doors: 7
Exit doors: 12
Resident sleeping rooms: 55
Battery operated smoke alarms: 6
Hazardous areas: 15
Sprinkler escutcheons missing: 5
Electrical receptacles failed testing: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Taylor Shuey | Executive Director | Named in exit conference and plan of correction |
| Maintenance Director | Involved in observations, interviews, and corrective actions | |
| Field Maintenance Supervisor | Involved in observations, interviews, and corrective actions |
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 5, 2023
Visit Reason
The visit was conducted for paper compliance to the Recertification and State Licensure Survey and in conjunction with the Investigation of Complaint IN00409906 completed on June 5, 2023.
Findings
Harrison Terrace was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding paper compliance to the Recertification and State Licensure Survey.
Complaint Details
Investigation of Complaint IN00409906 was completed on June 5, 2023; no deficiencies were cited.
Inspection Report
Complaint Investigation
Census: 69
Capacity: 69
Deficiencies: 1
Jun 5, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00409906 and was conducted in conjunction with a Recertification and State Licensure Survey.
Findings
The facility failed to provide appropriate treatment and supervision for residents with dementia to prevent intrusive wandering into other residents' rooms, specifically for 2 of 4 residents reviewed for abuse (Resident B and Resident D). Multiple behavioral incidents and interventions were documented, including one-on-one supervision and medication adjustments.
Complaint Details
Complaint IN00409906 was substantiated with Federal/State deficiencies related to allegations of failure to prevent intrusive wandering and related abuse incidents involving residents with dementia.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide appropriate treatment and supervision to residents with dementia to prevent intrusive wandering and related negative outcomes. | SS=D |
Report Facts
Census: 69
Total Capacity: 69
Survey Dates: May 31, June 1, 2, and 5, 2023
Medication Dosages: 200
Medication Dosages: 0.5
Medication Dosages: 25
Medication Dosages: 0.25
Medication Dosages: 0.5
Medication Dosages: 75
Medication Dosages: 5
Medication Dosages: 0.25
Medication Dosages: 0.25
Medication Dosages: 100
Medication Dosages: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natalie Bergman | DNS | Signed the report |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 5, 2023
Visit Reason
The visit was conducted as a paper compliance review related to the Investigation of Complaint IN00409906 completed on June 5, 2023, in conjunction with a Recertification and State Licensure Survey completed on the same date.
Findings
Harrison Terrace was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding paper compliance to the Recertification and State Licensure Survey.
Complaint Details
Investigation of Complaint IN00409906 completed on June 5, 2023; paper compliance was reviewed and found compliant.
Report Facts
Facility number: 241
Provider number: 155636
AIM number: 100291310
Inspection Report
Complaint Investigation
Census: 69
Capacity: 69
Deficiencies: 3
Jun 5, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted in conjunction with the Investigation of Complaint IN00409906.
Findings
The facility was found deficient in completing admission assessments and monitoring blood pressure for a resident readmitted after hospitalization, assessing and documenting pain appropriately for a resident receiving PRN pain medication, and providing appropriate supervision and interventions for residents with dementia exhibiting intrusive wandering behaviors.
Complaint Details
Complaint IN00409906 was investigated with Federal/State deficiencies related to the allegations cited at F744 regarding intrusive wandering and supervision of residents with dementia.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to complete an admission assessment and monitor a resident's blood pressure as planned after readmission. | SS=D |
| Failed to assess a resident's pain including location and intensity when providing PRN pain medication and ensure nonpharmacological interventions were provided. | SS=D |
| Failed to provide appropriate supervision and interventions to prevent intrusive wandering into other residents' rooms for residents with dementia. | SS=D |
Report Facts
Census: 69
Total Capacity: 69
Survey Dates: 4
Residents reviewed for hospitalization: 2
Residents reviewed for pain: 1
Residents reviewed for abuse: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natalie Bergman | DNS | Signed the report and involved in staff in-service regarding assessment and documentation of vital signs and pain. |
| Social Services Director 2 | Social Services Director | Provided interview regarding Resident D's wandering and behavioral issues. |
| Psychiatric Physician | Provided interview regarding Resident D's complex mental health diagnoses and medication management. | |
| Director of Nursing | DON | Interviewed regarding Resident F's admission assessment and Resident D's wandering behaviors and documentation practices. |
| CNA 6 | Certified Nursing Assistant | Interviewed regarding Resident D's wandering behaviors. |
| CNA 7 | Certified Nursing Assistant | Interviewed regarding Resident B's wandering and intrusive behaviors. |
| CNA 8 | Certified Nursing Assistant | Interviewed regarding Resident B found in other residents' beds and reporting to Executive Director. |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 71
Deficiencies: 0
May 18, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00407767 at Harrison Terrace.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00407767 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicaid residents: 55
Other residents: 16
Medicare residents: 0
Inspection Report
Complaint Investigation
Census: 73
Capacity: 73
Deficiencies: 0
Mar 17, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00395728.
Findings
No deficiencies related to the complaint were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Complaint Details
Investigation of Complaint IN00395728 found no deficiencies related to the complaint.
Report Facts
Census Bed Type: 73
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 56
Census Payor Type - Other: 16
Inspection Report
Complaint Investigation
Census: 64
Capacity: 64
Deficiencies: 1
Sep 7, 2022
Visit Reason
This visit was conducted for the investigation of complaint IN00389336 regarding allegations of resident to resident sexual abuse and substandard quality of care.
Findings
The facility failed to prevent resident to resident sexual abuse involving Resident B and Resident C. Interventions were not implemented per the plan of care, resulting in Resident B touching Resident C's private parts. Immediate Jeopardy was identified but removed prior to the survey after staff training and corrective actions were completed.
Complaint Details
Complaint IN00389336 was substantiated. The investigation found that Resident B, who had a history of inappropriate sexual behavior, touched Resident C's private parts on 8/26/22. The facility failed to implement interventions per the care plan and did not remove Resident C from Resident B's room in a timely manner. Immediate Jeopardy was identified on 8/26/22 and removed on 8/30/22 after corrective actions including staff training and room changes.
Severity Breakdown
Immediate Jeopardy: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure resident to resident sexual abuse did not occur, with Resident B touching Resident C's private parts. | Immediate Jeopardy |
Report Facts
Census: 64
Total Capacity: 64
Medicare residents: 2
Medicaid residents: 49
Other payor residents: 13
Survey dates: 2
Immediate Jeopardy duration: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 12 | Certified Nursing Assistant | Witnessed Resident B touching Resident C's private area and reported the incident |
| PCA 10 | Personal Care Assistant | Observed Resident B standing next to Resident C and reported unusual behavior |
| Executive Director | Executive Director | Provided information on staff training and policy regarding abuse and room moves |
| Facility Administrator | Notified of Immediate Jeopardy on 9/7/22 | |
| Director of Nursing Service | Notified of Immediate Jeopardy on 9/7/22 | |
| Regional Director of Clinical Service | Notified of Immediate Jeopardy on 9/7/22 |
Inspection Report
Re-Inspection
Census: 67
Capacity: 67
Deficiencies: 0
Jul 29, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00382965 and IN00376427 completed on June 23, 2022.
Findings
The facility was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the PSR to the Investigation of the two complaints. Both complaints were corrected.
Complaint Details
Investigation of Complaint IN00382965 and IN00376427; both complaints were corrected.
Report Facts
Census SNF/NF: 67
Total Capacity: 67
Census Payor Type Medicaid: 49
Census Payor Type Other: 18
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